his is the Season for Giving, and Senior Nurse Rizza Fernandez
engages volunteers from the Yours Today Choir (Top, Nurse Manager
Sarisahbi and her team Yi Ping, Rizza, Tadeja and Sharifah from TTSH
Buffer Stepdown Unit (BSU) Wards with choir leaders Mr Anthony Lim and
Ms Mary de Souza and members), as they encourage patients in longerstaying wards who await placement in suitable nursing homes. TTSH is
blessed with over 900 volunteers who selflessly give their time and talent
for our patients’ well-being and healing. Our close collaborations with
Nursing Homes in central region of Singapore under Project Care,
Community Rehabilitation, and other care initiatives also form a vital part
of the post-hospitalisation support system.

Community

ARTiculate!
ARTiculate! first began when a group of Medical Social Workers (MSWs)
from Tan Tock Seng Hospital (TTSH) started an acrylic painting session.
After an initial positive experience, they organised in-house sessions
for fellow MSWs and allied health professionals to bond and raise funds
for charity. These initial sessions opened the possibility of using art as
a medium to engage patients as well. This supported existing literature
that documents expressive art as a medium for psychosocial intervention.

Why ARTiculate! ?
ARTiculate! is envisioned to enhance
patients’ psychosocial well-being and
generate possibilities towards better
health. Facilitators are able to help
patients process and make meaning of
their inner self through this alternative
platform, where painting helps them
find words to express their thoughts
and feelings.
Participants of ARTiculate! include
persons who are living with chronic
conditions, mild cognitive impairment
and life-limiting illnesses, from the
young to the old.

To date, more than 8 sessions of
ARTiculate! have been conducted both
in the outpatient and inpatient settings.
ARTiculate! is one of the programmes
organised for the Singapore Patient
Conference in 2014 and TTSH World
Alzheimer’s Day 2015. Some of the art
pieces are displayed in communal
spaces in TTSH today. We can find them
in Care Connect, ward 83, ward 9C and
Department of Care & Counselling.
Mr T, described below, is an individual
who through ARTiculate!, was able to see
possibilities when his vision was failing,
resulting in better mental health.

Senior MSW Kelly said, “I have learnt
from facilitation of ARTiculate! that
it provides patients with a powerful
alternative means of sharing their
healthcare journey and offers the
hospital a creative way to document
value in outcomes that are not
easily quantifiable.”

Next Steps and how GPs can
work with us
• Collaborate with primary care
organisations to promote ARTiculate!
because the team believes everyone
can create art!
• Collaborate with local art schools to
expand the variety of expressive arts
in healthcare.
• Share patients’ healthcare journey
and stories through other platforms
such as a book on ARTiculate!
participants’ experiences, fund raising
exhibitions and exhibitions in local art
galleries to showcase their work.
,
To find out more about ARTiculate!
g
m.s
please email MSW@ttsh.co

Artwork 1

Artwork 2

Artwork 3

Artwork 4

When Mr T was first introduced to his multi-disciplinary
team, it was challenging to engage him in a meaningful
conversation. His usual response to the team would be
“I am okay” until he was invited to participate in
ARTiculate!. Artwork 1 was painted soon after Mr T
learned about his diagnosis. To Mr T, green bamboo is a
symbolisation of strength and served as a reminder to him
to be strong like bamboo, during his treatment. He drew a
panda with big eyes to symbolise his hope for improvement
to his impaired vision.
Unfortunately, Mr T did not experience improvement in his
impaired vision. Artworks 2 and 3 were painted when Mr T
completely lost vision in his left eye. He felt that his world
had turned black and white.

At this point, he was told that he needed a specific medical
treatment. In spite of the seemingly hopeless situation,
he chose to paint bamboo again to remind himself to stay
strong. Artwork 4 was completed when Mr T knew that he
was able to go for the specific medical treatment. He
painted red cherry blossom and wrote that spring has come
because he began to see hope.
From observation of Mr T’s experience, one could see that in
Asian healthcare settings, where expression of emotions can
be difficult for some patients, expressive arts can help them
express their emotions through the use of symbols and
metaphors. ARTiculate! appears to have much potential
contributing to the development of more culturally appropriate
practice in healthcare settings in Singapore.

01

Community

Did you catch CRiSP on Channel NewsAsia?

A/Prof John Abisheganaden sharing about the
challenges that SOCs are facing and the benefits
of a close collaboration with GP partners.

through the patient, GP, and hospital’s
perspectives.
Both A/Prof John Abisheganaden and Dr Low Kee Hwa of Low Medical Clinic in a joint interview for CNA’s
Singapore Tonight.

T

TSH Community Right-Siting
Programme (CRiSP) was
featured in Channel NewsAsia’s
Singapore Tonight on 24 June 2016.
The feature covered hospitals working
with General Practitioners (GPs) to
get more stable chronic-condition

patients treated outside the hospitals.
A/Prof John Abisheganaden, Clinical
Programme Director of TTSH CRiSP,
with one of our CRiSP GP partners,
Dr Low Kee Hwa of Low Medical
Clinic, were interviewed. They both
shared the benefits of the programme

Since CRiSP started in 2014, more
than 800 patients have been on this
programme, mainly for chronic health
management. This arrangement has
also led to the hospital saving around
2000 slots in its Specialist Outpatient
Clinics (SOCs) in the past two years,
and promoted closer collaborations
between GPs and Specialists.

Gold Award for CRiSP
in Asian Hospital
Management Awards
2016!

T

TSH Community Right-Siting
Programme is proud to announce
that we are the Gold award
winner for the Asian Hospital
Management Awards 2016. The award
honours hospitals in Asia that have
implemented or enhanced outstanding
and innovative projects, programmes,
and best practices during the
prescribed time period.
We would like to thank all our CRiSP GP
partners who have journeyed with us
over the past two years and for believing
in the spirit of the programme. We could
not have achieved this without your
strong support!

As we grow this programme to benefit
more patients in the community, we
seek more like-minded partners to
join us in this exciting journey of
primary care transformation.

Receiving the gold award for
Innovations in Hospital Management
and Governance category.

If you are interested to find out more,
please contact the Primary Care
Partners Office at GP@ttsh.com.sg.

Community

My Voice, My Care — Check
out our ACP Conversation
Starter today!

I

t’s important to make healthcare plans
for the future, to ensure you get the
medical care that you want.

Advance Care Planning (ACP) is a
voluntary process of discussion on future
care preferences between patients, their
loved ones, and healthcare providers.
The TTSH ACP team has consolidated a
set of guiding questions to help patients consider their
wishes, values and beliefs. Titled — My Voice, My Care — the ACP
Conversation Starter aims to prepare patients for an official ACP
discussion with a trained facilitator.
The benefits of ACP include:
• Understanding and reflecting on patient’s medical condition(s)
• Reducing loved ones’ burden in decision-making during difficult
situations
• Strengthening patient’s relationships with family
members and healthcare providers.
To find out more, scan the QR code or visit us at
www.ttsh.com.sg/acp

Journeying with you

T

TSH’s Department of Palliative Medicine is
organising its annual public forum, in
conjunction with World Hospice and Palliative
Care Day 2016! The forum will raise awareness and
understanding of the needs and concerns of
patients with life limiting illnesses. This year’s
theme — Journeying with you — recognises the
need to make information more accessible in the
community, as well as to provide continuing support
for patients and caregivers.
Join us at Toa Payoh
HDB Hub B1
Auditorium on 8
October 2016 to find
out how to care for
loved ones with
chronic and disabling
health conditions,
through personal
stories shared by our
healthcare team.

Register with us today by
scanning the QR code or going
to http://bit.ly/whpc2016

Nursing home residents get to remain in an environment familiar to them while receiving treatment from
the Project CARE team.

as well as emergency visits to provide
symptoms control or manage
exacerbations. Such collaborations

between TTSH and GPs have enabled
right-siting of care and reduced cost
to the healthcare system.

Nursing home GPs interested in participating in Project CARE can contact
Ms June Tan at 6359 6469.
03

Community

The Challenge
of Antimicrobial
Resistance to
Global Public
Health
By Dr Hsu Li Yang, Head and Senior Consultant,
Department of Infectious Diseases, Institute of Infectious
Diseases and Epidemiology (IIDE), Tan Tock Seng Hospital

A

ntimicrobial resistance’ is a term
commonly used in reference to bacterial
pathogens that cause nosocomial
infections. Because of their ability to adapt and
evolve, all microbes can develop resistance to
drugs used against them. Antimicrobial resistance
becomes an escalating problem in microbes that
cause human and veterinary disease, particularly
with tuberculosis and malaria.

Causes of antimicrobial resistance have been
reduced to a single axiom – antibiotic abuse and
overuse – and the problem is exacerbated by
globalisation, as well as a dearth of new drugs.
Solutions based on reduced parameters of
antimicrobial resistance will still be useful, but
present less of an impact or temporal durability
than anticipated.

Since its inception in 2001,
the National Health Group (NHG)
Eye Institute has continued to
address the increasing demand for
eye care services, and areas of its
research and training. It incorporates
Tan Tock Seng Hospital’s (TTSH) Department of
Ophthalmology as its flagship clinical unit, and
delivers quality tertiary and primary eye care to
patients in Singapore and the region. With more
than 32 fellowship-trained consultants on-board, the
Institute covers the entire spectrum of ophthalmic
subspecialties, providing comprehensive diagnosis
and advanced treatment for both common and
complex eye diseases.

I

n part three of the ‘Eye Discoveries’ series by the
NHG Eye Institute, we will be taking a look at the
evolution of cataract surgery, and the benefits
conferred to patients and surgeons, through the
introduction of Femtosecond Laser Assisted Cataract
Surgery (FLACS).
Cataract surgery has evolved rapidly over the years. The
last few years have seen the advent of a new technology
called FLACS, which promises advantages to both the
patient and surgeon.
Femtosecond lasers emit ultra-short pulses of energy
similar to those used in LASIK. The speed and accuracy
of the laser enables it to cut eye tissue with great
consistency and precision. With FLACS, this automated

to be created. The capsulorrhexis created by the laser
is shown to be consistently more circular than a
manually-performed one. In addition, as all corneas
experience some degree of endothelial cell loss after
phacoemulsification during cataract surgery, lower
amounts of ultrasound energy expended in FLACS may
also reduce the risk of corneal endothelium injury. All
these translate to potential improved visual outcomes
for the patient.
FLACS is an advanced and exciting technology that
offers various advantages. It is going to change the
way we routinely perform cataract surgery. Looks like
the time when a patient says that he had his cataract
‘lasered away’ has finally arrived.
laser can be used to create cornea wounds, open the lens
capsule and fragment the cataract into tiny pieces — steps
traditionally done by the surgeon manually. It can also be
used to reduce astigmatism during cataract surgery. All this
is achieved through high resolution scans of the eye during
the laser process. To complete the surgery,
phacoemulsification is used to remove the cataract
fragments, using ultrasound energy.
Femtosecond laser techniques allow for more precise and
consistent procedures. Although it is not possible to
completely avoid human errors, even the most complex
cases can benefit from FLACS, with reduced risk of surgical
complications. This offers a greater level of safety to both
the patient and surgeon alike. During cataract surgery, a
circular opening on the lens capsule (capsulorrhexis) needs

NHG Eye Institute Direct Access Hotline:
NHG Eye Institute is able to accommodate
same-day/next day appointments. Depending
on the level of care needed and the requested
timing, most patients can be seen by an Eye
specialist on the same day especially for
requests received in the morning.
For appointments, GPs should call 6359 6500.

05

feature

of the cutting instruments can be
reflected in real time. Ligamentous
balancing can be fine-tuned as well,
by studying the kinematics of the
replaced knee joint.

3D printing technology can also be used
in knee replacement surgeries. Patients
will undergo a pre-op MRI scan of the
lower limb, allowing the sizing,
positioning and alignment of the
implants to be pre-determined. These
3D printed patient specific instruments
(PSI) will fit onto the patients’ knee
joint perfectly, and allow the surgeons
to perform the knee replacements
quickly and accurately.
There are other benefits to these
techniques as well: reduced blood loss
and reduced risk of embolic events,
because the medullary cavity of the
bone will no longer be violated (a
requirement in traditional techniques).
Overall, “SMART” knee replacements
are well established in many centres
worldwide and have shown to improve
their accuracy and results.

W

e have to brace ourselves
to face the aftermath of a
rapidly aging population:
with an exponential increase in
patients suffering from osteoarthritis,
of which the knee joint is the most
commonly affected joint.
While early osteoarthritis can
be managed with medication,
physiotherapy and lifestyle
modifications, knee replacements
remain the only option for patients
suffering severe osteoarthritis.
A primary goal for knee replacement
is the restoration of the normal
alignment of the lower limbs.
Traditional techniques require a lot of
visual judgement from surgeons,

06

An example of intra-operative computer navigated
knee replacement.

this is prone to error and significant
malalignment was found in up to 30%
of the knee replacements – this will
significantly accelerate the wear and
tear, eventually leading to premature
implant failure.
With the aid of computer navigation,
the anatomical landmarks of operated
limbs are captured, and the alignment

An example
of the 3D
printed Patient
Specific
Instruments
(PSI) being
fitted onto the
distal femur.

Knee Replacement and other
orthopaedic-related services are
available at Tan Tock Seng Hospital’s
Orthopaedic Clinic B1B.
For appointments, GPs should call
6359 6500.

feature

IS ALL RHINITIS
DUE TO ALLERGY?
By Dr Lim Keng Hua, Consultant, Department of Otorhinolaryngology, Tan Tock Seng Hospital

How to know the cause of rhinitis?
A detailed history focusing on identifying the triggering
factor is taken. A thorough workout is performed to
establish the cause of rhinitis. An allergy test (e.g. a skin
prick test or in vitro testing) is performed to identify the
specific allergen. This guides allergen avoidance and
immunotherapy. A nasoendoscopy is performed to exclude
structural causes and tumour.

Nasoendoscopy and other otorhinolaryngology-related services are available at
Tan Tock Seng Hospital’s ENT Clinic (Clinic 1B). For appointments, GPs should call
6359 6500.

This Christmas, let’s remember
that health is the greatest gift, with these
healthy eating tips prepared especially for
the occasion.
Indulge in a
balanced meal
Be it a buffet or Christmas roast,
remember to portion half of your plate
with fruit and vegetables, a quarter
with lean meat, and the other quarter
with whole-grain food.
Enjoy treats in
small amounts
Sugar-filled cakes and desserts can
cause weight gain in excess. Limit your
sugar intake to less than 10 teaspoons
daily – a slice of cake or a bar of
chocolate contains 4 teaspoons each.

Drink wisely
Water or sugar-free
beverages are wise choices to consume
for parties and celebrations. If you
consume alcohol, remember to limit
it to a standard drink for ladies and
two standard drinks for men, per day.
A standard drink equates to a can of
beer (330ml); half glass of wine (175ml);
or a shot of hard liquor (35ml).
Don’t forget
to keep active
Participate in moderate-intensity
physical activity five days weekly
for around 30 minutes each, to work
off the excess food consumed.

abacavir. Since 29 September 2013,
the Singapore Ministry of Health
mandates that clinicians ascertain
the HLA B*1502 status before
prescribing carbamazepine.

the active form by CYP2C19. Slow
metabolisers experience diminished
anti-platelet effect. Similarly, codeine
is activated by conversion to morphine
by CYP2D6; ultra-metabolisers may
develop toxicity.

M

edicines don’t always work as
we’d like them to. Doctors
would be very happy to be
able to predict the result of a
medication in any given patient, and
the fact is, tests do exist, some of
which we shall discuss.
The cytochrome (CYP) system is an
important route for metabolising drugs.
Concentrations of psychiatric drugs such
as amitriptyline, clomazepine, and
fluoxetine may be excessive in patients
with low CYP2D6 metabolic activity.
Clopidogrel, a pro-drug, is converted to

Variants in the thiopurine
methyltransferase enzyme and
NUDT15 genes determine the risk of
leucopaenia due to thiopurines such as
azathioprine. The effect of warfarin is
influenced by VKOR1 and CYP2C6.

It has been hard to show conclusive
proof of cost-effectiveness in all cases.
This means that administering tests and
using non-cross-reacting alternatives
cannot be shown to be consistently
cheaper than simply not testing and
treating adverse reactions as they arise.

HLA B*1502 is associated with severe
cutaneous allergic reactions due to
carbamazepine, HLA B*5801 to
allopurinol and HLA B*5701 to

As we understand more about the
performance of these tests, they will
become routine in our medical practice
in the immediate future.